Snus use in football: the threat of a new addiction?

The use of Snus, an oral nicotine pouch, is becoming increasingly common in English professional football. As a nicotine product, Snus raises important questions about health and performance for practitioners. The purpose of this short communication is to explain the current regulatory status of Snus, performance relatedeffects, and associated health outcomes. Further, based on player statements and evidence from the general public, we argue that Snus is used as a coping mechanism to deal with the stressors of professional football. Accordingly, the communication concludes with guidance for club-level multidisciplinary interventions to support player welfare, aimed at reducing Snus use as well as future research recommendations.


ABSTRACT:
The use of Snus, an oral nicotine pouch, is becoming increasingly common in English professional football.As a nicotine product, Snus raises important questions about health and performance for practitioners.The purpose of this short communication is to explain the current regulatory status of Snus, performance relatedeffects, and associated health outcomes.Further, based on player statements and evidence from the general public, we argue that Snus is used as a coping mechanism to deal with the stressors of professional football.Accordingly, the communication concludes with guidance for club-level multidisciplinary interventions to support player welfare, aimed at reducing Snus use as well as future research recommendations.We provide a summary of the health and performance effects of Snus and nicotine, arguing that Snus use should not be considered an independent behaviour.Rather, a response to significant footballspecific occupational stress warranting an interdisciplinary approach to reduce its widespread use, yet poorly understood effects, on player health and performance.

Is Snus legal?
Snus is not prohibited by the World Anti-Doping Agency (WADA) as a performance enhancing substance or controlled substance.Nicotine is however, on the WADA 2023 Monitoring Programme for in-competition use as a stimulant.Nicotine primarily acts as a neuroregulatory agent on neuronal nicotinic acetylcholine receptors in the central and peripheral nervous system, releasing dopamine via the mesolimbic pathway [14].It has stimulatory effects in lower doses whilst depressing the central nervous system in higher doses leading to feelings of relaxation [15].Analysis of 60,802 in-competition antidoping urine samples taken in Italy from 2012-2020 reported that on average, 22.7% (15.2-32.5%) of all samples indicated nicotine intake, increasing to 29% (18.4-40.4%) in football [16].The nicotine content in commercially available pouched Snus from Europe is comparable to a cigarette (approx.15mg per product) [17].However, it leads to significantly higher plasma nicotine concentration than smoking due to the longer use duration [17].The nicotine Short Communiction athletic populations.Nicotine is a highly addictive compound and anecdotal reports suggest that dependence is becoming more common in football [8].Like other addictions, nicotine dependence is associated with mental health issues and may lead to adverse physical and psychological withdrawal symptoms [26].For example, short-term abstinence from nicotine can lead to intensified moodrelated symptoms including anxiety and depression [27].On balance, using Snus as a stress-coping method has the potential to cause social, physical, and mental harm undermining players' performance and recovery.

Reducing Snus Use
A central premise of this manuscript is that Snus use can be viewed as a maladaptive stress management strategy for football-related occupational stress.Smoking cessation, appetite suppression, and pre-match psychological reassurance have been cited as motivations for Snus use.Yet anecdotally the most frequently stated reason is for recreational relaxation as shown in Figure 1, aligning with research examining smokeless tobacco users in sporting samples [28] and Snus use in the general public [13].
Paradoxically, Snus use may enhance the risk of performance, injury and ill-health, a significant stressor for professional athletes.
Yet instigating changes towards more positive health behaviours in athletes remains difficult and education alone is often insufficient [29].
In practice, an interdisciplinary approach that not only provides information concerning health risks but situates Snus use within broader strategies to improve athlete mental well-being is required.For example, psychologists can help footballers to cope with underlying mental health status and sport specific stressors by understanding player history, peer-pressure, social supports, motivation for use, and providing evidence-based interventions (e.g., cognitive behavioural therapy).It is important that when discussing Snus use and potential cessation strategies that conversation is framed against factors valued by players to promote engagement, such as any potential negative impact on their performance.Likewise, routine enquiry and education by medical staff, identification of at-risk players through daily well-being reporting by staff with frequent interaction (e.g., physiotherapists, S&C staff), and monitored pharmacotherapy for nicotine dependence, could all contribute to identifying, preventing, reducing, and hopefully stopping Snus use.Lastly, given that occupational stressors are inherent in a professional football career, ongoing work to promote mental health awareness and reduce barriers to seeking mental health support may encourage more adaptive methods for coping with stress at an individual and club level [30].

CONCLUSIONS
Recognising the inherent data limitations, the illustrative player testimonies presented in Figure 1 support a call for more research and systematic reviews examining Snus use in elite sport.We outline six future research avenues that could develop our understanding of content and carcinogen content of Snus products varies considerably between products [18].Indeed, Swedish Snus has greater levels of unionized nicotine in comparison to US products meaning nicotine can be absorbed quicker across mucous membranes leading to a 'greater nicotine reward' [19].
It is not illegal to possess or consume Snus in the UK, but it is illegal to sell.Player testimonies suggest that purchasing Snus online through social media and illegal websites or from other players is common.This raises questions about substance propriety (e.g., contaminated products that may trigger anti-doping rule violations) alongside legal and employment implications for any players caught selling Snus to teammates [7].Ultimately, whilst nicotine remains legal from an anti-doping perspective, there is no policy incentive for players to change their behaviour.Instead, Snus use should be treated as a matter of professionalism, like alcohol and smoking, with concern concentrated on player health and team performance.

Does Snus Impact Performance or Recovery?
A recent review of the limited studies concerning oral nicotine and Snus use in sport concluded that performance enhancement was unlikely and performance may even diminish [6].A broader review of nicotine's impact on performance (aerobic, anaerobic and muscular) also concluded that ergogenic effects were unlikely, however, the available evidence quality for this conclusion was low [20].Opposingly, meta-analytical findings support that nicotine can enhance some cognitive abilities on tasks involving fine motor skills, attention, and memory [21].Further, the calming effects of high-dose nicotine described by users may offer short-term protection against the impact of stress on performance.Although, determining the impact of nicotine on performance is complex and often confounded by sampling of nicotine in naïve and chronic user participants.Indirectly, nicotine use is associated with sleep impairment [22] and the deleterious effects of limited sleep on athletic performance and recovery are well documented [23].Equally, nicotine can lead to increased metabolic energy expenditure, reduced body weight, and appetite suppression [24] meaning Snus use may challenge optimal nutritional support for athletic performance and recovery.Therefore, chronic Snus use has the potential to undermine performance/recovery via impaired sleep and potentially diet.

Figure 1 )
Figure 1) including: (i) increased risk of periodontal disease; (ii) heat intolerance; (iii) impaired cardiovascular function; (iv) metabolic syndrome; and (v) increased mortality rates, caveated with the need for more robust studies in sport-specific populations.More broadly, meta-analytical results from military training studies indicate an